Disclosures Chronic Pain Management and the Use of Opioid ......•2016: 42,249 1.CDC. Multiple...

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Chronic Pain Management and the Use of Opioid Medications: The CDC

Guideline and BeyondDavid Anisman, MD

Medical Director, Farmington Health Center (Primary Care)

Associate Medical Director, Community Physicians Group

Disclosures• None

Overview• Scope of the opioid problem• Brief history of pain and opioid prescribing• CDC Guideline review• CPG Guideline and policy highlights• Barriers to safe and effective practice• Call to action

Scope of the Opiate Problem• Nationally

– 1999-2014: >165,000 deaths from prescription opioids alone1

– Deaths from all opioids now > HIV + MVA (+CAD)• 1999: ~8,500• 2015: 33,000• 2016: 42,249

1.CDC. Multiple cause of death data on CDC WONDER. Atlanta, GA: US Dept of Health and Human Services, CDC; 2016

Scope of the Opiate Problem• Utah1

– Rank in US for prescription opioid deaths• 2013: #8• 2014: #7• 2016: #20 (but no change in death rate)

– Death Rate (per 100K population)• 2014 = 22.4, 2015 = 23.4, 2016 = 22.4

– 23 Utahns die every month from prescription opioids

1.Utah Department of Health website

Prescribing Rates (per 100K population) - 2012 81.3/100K (255M)

- 2016: 66.5M (214M)- 18% ↓

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Prescribing Rates (per 100K population)

Scope of the Opiate Problem• Death Rate (per 100K population)

– 2014 = 22.4, 2015 = 23.4, 2016 = 22.4 (no change)• UT Prescribing rates:

– 2014 = 78.9/100, 2015 = 74.5/100, 2016 = 70.4/100 (10.7% ↓)• Why no correlation? Need to address other risks:

– High dosages– High-risk combinations– Inappropriate diagnoses (missing SUD?)

1.CDC. Multiple cause of death data on CDC WONDER. Atlanta, GA: US Dept of Health and Human Services, CDC; 2016

Utah rates:- 2015 - 2016: 4.3 - 5.6/100K- 30.2% increase

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Scope of the Problem: The Key Actors

1. State Legislatures

– Washington State 1st; UT HB 50 & 90 (2017)

– Focus: limiting amount prescribed

2.Federation of State Medical Boards (recommendations, CME requirements)

3. Payers (Regence BCBS in Massachusetts)

Scope of the Problem: The Key Actors

• Medical Community– Largely silent– Professional Societies: CME requirements for MOC– CDC Guideline

• Primary Care Providers– Inadequate training1

– Account for nearly 50% of opiates dispensed2

1. Jamison et al. Beliefs and attitudes about opioid prescribing and chronic pain management: survey of primary care providers. J Opioid Management 2014; 10:375.2. Levy B et al. Trends in opioid analgesic prescribing rates by specialty, US, 2007-12. AM J Prev Med, 2015: 49:409.

Opioid Prescribing: a brief history• Prescribing trends follow several developments

– Development of meds and delivery systems– Rise of Pharma as driver of prescribing practices– Progress of neuroscience

Opioid Prescribing: a brief history• Early 19th Century: “pain is good”

– Improved healing via stimulation of CV and immune function

• 1850s: “pain should be eliminated”– Development of new meds– Development of hollow bore needle

• Today: “Pain is bad for health”–Directly responsible for increases in opioid

prescribing• Acute pain pathways: peripheral NS (fact)• Chronic Pain: Development of central pathways that

sustains pain perception without input from the peripheral NS (theory)

Opioid Prescribing: a brief history• 1980s: State regulations prevented Pharma from

incentivizing providers directly

• Ex: Purdue Pharma and JCAHO– JCAHO used Purdue’s videos as training materials– Tied pain control to Quality measures– Created analog pain scale (“5th VS”)

Opioid Prescribing: a brief history

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3 Opioid Myths1. “Effective for long-term pain control”2. “No dose is too high”3. “Not addictive if given for pain”

Opioid Prescribing: a brief history CDC Guideline: Data• Good data on opioid effectiveness for acute pain1 and

cancer pain• Few studies on long term benefits of opioid for chronic

pain• What evidence there is suggests “serious harms that

appear to be dose-dependent”2

1.Chou R, et al. The effectiveness and risks of long-term opioid treatment of chronic pain. AHRQ Pub #14-E005-EF, 2014.2.CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016, p9.

CDC Guideline: DataOdds Ratio of Overdose by Opiate Dosage (relative to 1-19 MME/day)

Opiate Dosage Ranges (MME/day)

OR of Any OD Event OR of OD Death

20-49 1.44 1.32

50-99 3.73 1.92

100-199 8.87 2.04

>200 2.88

Dunn DM, et al. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med 2010; 152;85Gomes T, et al. Opioid dose and drug-related mortality in patients with nonmalignant pain. Arch Intern Med 2011; 171:686

CDC Guideline: When to Initiate or Continue

• Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain.

• Consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient.


• Establish treatment goals (including function)

• Continue opioid therapy only if there is clinically meaningful improvement (and function)


Discuss known risks and realistic benefits of opioid therapy and patient and clinician responsibilities for managing therapy

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CDC Guideline: Opioid Selection, Dosage, Duration, etc.

Prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids


• Prescribe the lowest effective dosage• Reassess benefits & risks when considering

increasing dosage to ≥50 morphine milligram equivalents (MME)/day

• Avoid increasing dosage to ≥90 MME/day


• Long-term opioid use often begins with treatment of acute pain.

• Three days or less will often be sufficient; more than seven days will rarely be needed


• Evaluate benefits & harms within 1 to 4 weeks of starting/escalating

• Re-evaluate every 3 months or more frequently. • If benefits do not outweigh harms, work to taper or

discontinue opioids

CDC Guideline: Assessing Risk and Addressing Harms

• Evaluate risk factors for opioid-related harms.

• Consider naloxone if increased risk for OD, to include dosages (≥50 MME/day)


• Review PDMP ( = CSD in UT)

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• Use urine drug testing before starting opioid therapy and at least annually


• Avoid prescribing opioids & benzodiazepinesconcurrently whenever possible


• Offer/arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder

CPG Guideline & Policy

• Rationale

–PCPs can no more be excused from addressing their patients’ chronic pain than they can be expected to prescribe opioids in every case or in an unlimited manner.

–Assist PCPs in deciding when to treat with opioids and when not to

CPG Guideline & Policy• Rationale

–Provide institutionally-endorsed limits for opioid dosages

–Provide workflow options to facilitate safe and appropriate opioid management

–Reduce both the risk to the provider as well as conflict with patients

CPG Guideline & Policy• Proper assessment: thorough Hx (pain and PMH)

– Effective and ineffective treatments– Impact on function (2 Item Graded or PEG)– Screen for mood disorders (PHQ-9 & GAD)– Opiate Risk Tool (ORT)– CAGE-AID– UDS– CSDB review

• No opioids at the first visit!

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2 Item Graded Pain Scale PEG

CPG Guideline & Policy: Who to Treat, Who Not to Treat

• Reasonable• Cancer pain• Moderate-severe arthritis & DDD• Spinal stenosis• Some neuropathic pain• RLS


• Caution Advised• Psychiatric co-morbidities• Renal & hepatic disease• Pulmonary disease• Lack of engagement in full treatment plan• Unclear Diagnosis • History of treatment by multiple providers


• Discouraged• Migraine (and most headache)• Fibromyalgia (and most myofascial conditions)• Mechanical low back pain• Sciatica• History of substance abuse (tobacco?)

CPG Guideline & Policy• Medication Specifics

– Dosage limits• Re-evaluate annually

• 90 MME/day: bi-annual review/referral (clinRx, BH, pain specialist)

– Sleep testing for >90 MME/day (lower if pulm dis)– Start with short-acting– Avoid dangerous combos (benzos strongly discouraged;

SOMA prohibited)

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• Medication Specifics–Methadone only if provider experienced–No meperidine (Demerol)–Naloxone > 50 MME/day–Tapering protocol


Workflow Expectations1. Controlled Substance Agreements2. No refills without a clinic appointment3. One provider, one pharmacy4. UDS at least annually5. Schedule follow-up at each refill appointment


Workflow Expectations6. Continually monitor function, not just pain7. Document treatment goals and progress8. 5As9. Patient Education

5As


• Mandatory use of formatted pain note in EMR

• Mandatory documentation of treatment goals, ineffective treatments

• Must have a specific, legitimate diagnosis

Barriers to Policy Implementation• Provider discomfort with opiate prescribing & managing

chronic pain– Unethical to refuse to address & manage pain– No obligation to treat unsafely (think: antibiotics)

• Takes time• Patient expectations & impact on satisfaction• Learning to say “no” and set boundaries with kindness

and empathy

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A Call To Action!Create Your Own Policy

• Recommendations vs Mandatory Limits• Dosage limits (# pills vs MME/d)• Documentation requirements• No refills without an appointment• Dedicated refill appointments• Use of CSDB every time• UDS• Medication specifics• Provide support resources as much as possible

Visit the CDC Website!

• www.cdc.gov• search by alphabet: O; pick “Opioids”• Guideline Resources: Clinical Tools

Questions?• [email protected]

• 801-213-6747

• Within the UofU: SmartWeb

Disclosures Chronic Pain Management and the Use of Opioid ......•2016: 42,249 1.CDC. Multiple...

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